CJK 07. Microsurgical varicocelectomy at Toho University

We describe the treatment of symptomatic recurrent varicoceles accompanied by scrotal pain or scrotal swelling. High ligation had been previously performed for varices in the spermatic cord. We used venography to determine the cause of abnormalities. In contrast to low-ligation microsurgery for spermatic cord varices, a greatly enlarged vas deferens vein had been anastomosed to the superior segment of the internal spermatic vein, and through the vas deferens vein, which resulted in swelling in scrotal veins.

In low-ligation microsurgery for varices of the spermatic cord, blood flow direction is determined with a patency test during anastomosis of blood vessels, and retrograde blood flow is confirmed in the enlarged vas deferens vein. Kim et al. (1) reported successful ligation and isolation of all veins with a diameter of 2 mm or more, without delivery of the testes, and preservation of all arterial function. Thus, only vasal veins with a diameter of 2 mm or more were ligated in the present patients. We describe procedures we performed in 2011 on internal and external spermatic veins, and on vasal veins with a diameter of 2 mm or more.

During the 4-month period from December 2010 through March 2011, our department treated 17 cases of spermatic veins requiring ligation: 13 due to infertility and 4 due to scrotal pain. All patients underwent semen analysis and/or ultrasound examinations at a 3-month follow-up examination.

Among the 13 men with infertility, age ranged from 30 to 49 (mean, 39.3) years, and the age of their wives ranged from 28 to 41 (mean, 35.2) years. Before receiving varices treatment, they had received assisted reproduction treatment, including treatment for the wife (1 case), oral medication for the man (1 case), artificial insemination (5 cases), and in-vitro fertilization (5 cases). Almost all these treatments were performed in a gynecology department. Preoperative ultrasound imaging revealed a grade III varicocele, and in 1 such case varicoceles were bilateral. Preoperative follicle-stimulating hormone was elevated in 3 patients (1 of which also had azoospermia), and 1 patient was positive for anti-sperm antibodies, but without unusual findings on tissue staining.

The patients were anesthetized with an approximately 15 ml solution of 1% Xylocaine and 0.75% ropivacaine (Anapeine) administered locally to the area just above the external inguinal ring. A 3-cm transverse incision was made, and the presence of the spermatic cord was confirmed. The spermatic cord was elevated with a small Richardon retractor, as were surrounding tissues, insofar as this was possible, and a mosquito clamp was placed under them. They were then microsurgically ablated, and adipose tissue, lymph ducts, nerves, arteries, and the vas deferens were each moved under the mosquito clamp. A Doppler flow meter was used to confirm pulses in blood vessels. When a pulse was detected, the blood vessel was ablated and isolated with particular care. Vessels with no pulse were doubly ligated with 3-0 silk thread and then ablated. Anterior to these vessels are the external wall of the spermatic cord, adipose tissue, nerves, lymph ducts, the cremasteric muscles, and the external spermatic blood vessels, including the cremasteric artery and vein. Only the external spermatic veins were doubly ligated and ablated. A 1-cm opening was then created in the tunicae funiculi spermatici, the vein was ligated and ablated, and structure other than this vein were moved below the mosquito clamp. If the vas deferens was visible, the location of the deferential artery was confirmed, and the deferential vein was ligated and ablated.

When the internal spermatic vein was enlarged anteriorly, it was detached from surrounding tissue and then ligated and ablated. Vessels in which the Doppler blood flow meter revealed a pulse were isolated with extra care. It should be noted that although arteries are sometimes a distinctive red-black color, they sometimes have a color that makes them difficult to distinguish from veins. The absence of a pulse may be due to contraction of the artery, and such arterial spasms can be relaxed by directly applying anesthesia. The total number of veins requiring ligation and ablation was 3 to 10 for external spermatic veins, 3 to 8 for deferential veins, and 10 to 30 for internal spermatic veins; the presence of 2 to 5 arteries was also confirmed.

As there was little blood loss, there were no problems regarding blood loss, and the use of a bipolar sealer was not required. In closing, 3 sutures of 3-0 Vicryl were required to close subcutaneous tissue, and 3 or 4 sutures were required to close the dermal tissue; no skin sutures were needed. Operative time ranged from 1 to 1.5 hours, and although slight transitory pain was sometimes reported by patients during the procedure, no procedure was ended prematurely. Postoperative discomfort was alleviated with 2 to 3 doses of standard oral analgesics, and patients were able to return to work on the day after the procedure. Patients were instructed to keep the surgical area dry when bathing on the day of the procedure, but not on subsequent days. Exercise was permitted 1 week after surgery. The site was inspected 7 to 10 days after surgery. Sperm tests and ultrasound testing were performed 3 months after surgery.

Pre- vs. postoperative sperm findings were as follows: semen volume (ml) 2.7 vs. 3.5 (P=0.0218), sperm concentration (10,000/ml) 1258 vs. 2935 (P=0.0009), motility rate (%) 10.2 vs. 17.9 (P=0.0284), desirable motility rate (%) 1.2 vs. 4.6 (P=0.0090), total number of active sperm (10,000) 170 vs. 1124 (P=0.0007). All differences were statistically significant. Furthermore, active sperm were detected in patients who had no preoperative sperm activity. Improved semen findings were even noted in patients that were positive for antisperm antibodies.

The 4 patients reporting scrotal pain ranged in age from 29 to 37 (mean, 33.8) years and were not in a sexual relationship at the time of treatment. At a follow-up examination and ultrasound 3 months postoperatively, pain had disappeared in 3 of the 4 cases, and had decreased in the fourth patient. Ultrasound revealed satisfactory results in all 4 cases.

All 17 patients who underwent vasal vein ligation (for veins ≥2 mm in diameter), were able to walk home unaided, and only 2 or 3 doses of oral analgesics were required. There were no other postoperative complications, eg, systemic infection, testicular hydrocele, and microrchidia. Some patients reported slight bleeding from the incision that resolved with time. There were no cases of remaining varices.